Monday 13 August 2012 04.30 EDT
First published on Monday 13 August 2012 04.30 EDT

The health service reforms provide a dilemma for the government over the management of the increasing numbers of people with long-term health conditions.

On one hand, the marketisation of the NHS may produce economies of provision but on the other will result in a breakdown of co-ordination among providers. A multiplicity of providers involved in the care pathway for even one chronic disease will make co-ordinated or integrated care difficult to achieve.

For example, a patient with chronic respiratory disease may receive medical services from primary care and hospital doctors and therapists. They may have oxygen from one supplier and rehabilitation services from another. Since many people with one chronic disease are likely to also have another, a multiplication of services will become confusing for the individual.

It is very unlikely that the different providers involved will share potential commercially sensitive information to achieve integration. In the US, disease management programmes acknowledge this difficulty by ensuring that one provider covers all the components required including secondary care, primary care and any therapy services.

This is not seen as the model in England where a "free for all" tendering process from any qualified provider is envisaged.

As with previous health service reforms, healthcare professionals will try their hardest to introduce the good ideas and limit the damage caused by the ill-thought through aspects. One way of trying to encourage uniformly high standards of care is for the profession and patients to work together to identify quality standards for individual conditions that describe the best provision.

Variance from the highest standards can then be used by patients to challenge commissioners and providers if they fall short. Nice has already been commissioned to produce some quality standards but do not have the capacity to cover every condition. The specialist societies and patient organisations can take on this role.

The quality standards just produced by the British Thoracic Society (BTS) for bronchiectasis are a good example. Bronchiectasis is an extremely common but little known chronic condition, often due to childhood illness that results in frequent respiratory infections requiring antibiotic treatment and sometimes hospital admission.

Modern management of bronchiectasis will benefit the patient but most commissioners or general practitioners will have little knowledge of the condition. Since Nice had no plans to develop guidance in this area, the BTS has produced the world's first evidence-based clinical guidelines and quality standards. The latter will set out what patients will expect and hopefully provide a degree of co-ordination by contractual adherence to common standards.

Partnerships like this, between patients and their healthcare providers, provide the basis for the development of a proactive healthcare model suited to chronic disease. They may also serve to point out the fallacy of the belief that the marketisation of healthcare alone can improve the effectiveness of services for long term conditions.